Lobectomy versus sublobar resection in elderly patients with early-stage NSCLC (≥70 years): a dual-cohort study of perioperative and oncologic outcomes

Objectives To evaluate the perioperative safety and long-term oncologic outcomes of lobectomy versus sublobar resection in elderly patients (≥ 70 years) with early-stage non-small cell lung cancer (NSCLC) ≤ 3 cm. Methods A dual-cohort study was conducted. First, the SEER database (2000–2022) was queried for patients ≥ 70 years with NSCLC ≤ 3 cm, utilizing 1:1 propensity score matching (PSM) (n = 769/group). Second, a real-world retrospective analysis of 223 elderly patients from two tertiary hospitals was performed. In the real-world cohort, perioperative complications were analyzed using the entire unadjusted population to reflect clinical practice, while 3-year overall survival (OS) was evaluated after 2:1 PSM to minimize selection bias. Results In the SEER cohort, lobectomy provided a significant 5-year OS advantage for tumors 2–3 cm (P = 0.021), whereas survival was comparable for tumors ≤ 2 cm (P = 0.057). Real-world data corroborated these trends: after PSM, no significant difference in 3-year OS was observed between lobectomy and sublobar resection for tumors ≤ 2 cm (94.29% vs. 86.36%, P = 0.40). However, lobectomy demonstrated superior OS for the entire ≤ 3 cm matched cohort (P = 0.018). In the unadjusted perioperative analysis, sublobar resection was associated with significantly shorter chest tube duration (3.9 vs. 6.8 days, P < 0.01) and a lower incidence of surgical-related complications (P < 0.05). Notably, only 10.76% of high-risk patients received indicated adjuvant therapy, highlighting a significant gap in treatment compliance. Conclusions Sublobar resection is a viable, lung-sparing alternative for elderly patients with peripheral NSCLC ≤ 2 cm, offering reduced perioperative morbidity without compromising survival. For tumors > 2 cm, lobectomy remains the oncological standard due to superior survival. Enhanced postoperative management and tailored follow-up strategies are essential to improve treatment adherence in this aging demographic.